Healthcare Provider Details

I. General information

NPI: 1467758789
Provider Name (Legal Business Name): MIZPAH GROUP HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2011
Last Update Date: 02/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31058 WHEATON 201
NEW HUDSON MI
48165-9469
US

IV. Provider business mailing address

31058 WHEATON 201
NEW HUDSON MI
48165-9469
US

V. Phone/Fax

Practice location:
  • Phone: 248-796-2639
  • Fax:
Mailing address:
  • Phone: 248-796-2639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. ALONZO KEVIN MORGAN SR.
Title or Position: PRESIDENT
Credential: MA
Phone: 248-796-2639